STUDENT’S NAME __________________________________ PARENT’S NAMES _________________________________
STUDENT’S BIRTHDATE _____________________________ ENTERING GRADE ________ ON SEPTEMBER 1, 2010
EMAIL__________________________ HOME PHONE # _____________________ CELL PHONE # ___________________
STREET ADDRESS ___________________________________ TOWN _____________________ ZIP CODE__________________
EMERGENCY CONTACT __________________________________EMERGENCY CONTACT PHONE #________________________
RELATIONSHIP TO STUDENT __________________________________________________________________________________
ALLERGIES/PHYSICAL LIMITATIONS
______________________________________________________________________________________________
______________________________________________________________________________________________
PHYSICIAN’S NAME____________________________________ PHONE_______________________________________
PHYSICIAN’S ADDRESS_______________________________________________________________________________________
INSURANCE COMPANY ___________________________________ POLICY NUMBER____________________________________
PREVIOUS DANCE EXPERIENCE:
DANCE SCHOOL _________________________________________________________________ YEARS ____________________
TYPES OF
DANCE____________________________________________________________________________________________________
PHOTO RELEASE
I, _________________________________, the parent of _______________________________________________
(Please circle one) GIVE / DO NOT GIVE The Medway Dance Authority permission to use my child’s photos from studio events,
recital photos, etc. for use on The Medway Dance Authority Website, Advertisements & Brochures.
Signed________________________________________ Date _________________________________
How did you hear about the The Medway Dance Authority (Please circle):
Website Newspaper Business Card Display Referred By: _________________________________
REGISTRATION FEES
$25.00 Single Student Registration Fee OR $40.00 Family Registration Fee
All currently enrolled students may register as of April 1st – NO SOONER!!! Forms turned in early will be returned.
Siblings must wait until April 15th to enroll but should turn in forms before the 15th for preferred placement over new students.
Registration forms may be mailed to: The Medway Dance Authority P.O. Box 150 Medway, MA 02053
Priority enrollment for current students will be April 1st – April 14th. Registration will be first come, first serve during this time for current
students. If you need a particular day and time you should try to register early. You may enroll by filling out this registration form and
enclosing it in an envelope with your registration fee (see fees above). Please make sure you fill in the correct day, time, and cost of
classes. Please call first if your child wishes to try a new style of dance. His/ Her class may not be the level indicated above and he/she
may need to wait for a slot to open. If you do not hear from us your child will automatically be enrolled in the programs you have
requested on the back of this form. If a class is full we will contact you immediately! Please call 533-9171 with any questions you may
have!
REGISTRATION FORM & CONTRACT
Please register my child, _________________________________ for the 2010 - 2011 dance season. I have enclosed my non-
refundable registration fee of $25.00 for a single student or $40.00 for a family registration to register for the classes below. I will
contact The Medway Dance Authority by September 1, 2010 if we will not be able to attend the 2010/2011 season. I understand that
tuition, if not paid in full by September 1, 2010 will always due by the 1st day of each month (September 1st – May 1st ) and that I will
be charged a $10.00 late fee after the 1st day of the month. I understand that I will NOT receive the 10% multi-class discount if my
payment is late and will also be required to pay the $10.00 late fee. I also agree to pay a $20.00 penalty for any returned checks.
I understand that the costume payment of $60.00 per class is due by October 15, 2010. This payment must be made separate from
tuition and is non-refundable. However, if the costume payment has been made, but the child is unable to continue in the dance
program, he/she will still receive his/her costume.
I understand my payment options. I understand that payment may be made in full for the year by September 1st or I may choose to
make 9 equal payments September 1st – May 1st. I understand that tuition is based on the dance season, not based on how many
classes per month.
I understand that my child must follow all studio rules and safety regulations. My child will also be at class on time so that he/she will not
miss critical warm up exercises. I understand and my child understands that by missing class time and by not following rules, he/she
runs the risk of injuring himself/herself. I also understand that with any physical activity, including dance, there is always a risk of injury
and I will not hold The Medway Dance Authority, it’s staff and it’s representatives responsible for any injuries or loss of valuables that
may occur during the program.
I, __________________________________________________ and my child____________________________________________
will follow all of the rules & regulations of The Medway Dance Authority as outlined in the handbook. 2010/2011 handbooks must be
picked up by a parent or guardian at the first dance class in September.
Please register my child, ___________________________________________ for the following classes.
CLASS DAY TIME COST
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
YEARLY TUITION TOTAL MONTHLY INSTALLMENT TOTAL (If you choose Option C)
____________________ _________________________________________________
Families enrolled for more than 1 class may take a 10% discount monthly if payments are made by the 1st day of each month!!!
1ST payment of Option 3 monthly installment payment plan due by September 1, 2010
Receive a 5% discount if full year is paid by June 15, 2010
(May be combined with 10% multi –class discount if you are eligible)
REGISTRATION FEE DUE NOW!!!
$25.00 single student/$40.00 Family
______OPTION A I choose to Pre-pay the 2010/2011 Season in full by June 15, 2010 to receive the extra 5% Discount (10% Multi-
class discount may also be added if applicable for a savings of 15%) Payment may be dropped off at the dance studio or mailed to: The
Medway Dance Authority P.O. Box 150 Medway, Ma. 02053
______OPTION B I choose to pay for the 2010/2011 season in full by September 1, 2010 (10% Multi-class discount may be taken if
applicable )
______ OPTION C I choose to break my 2010/2011 payment into 9 payments, due September 1, 2010 through May 1, 2011 (10%
Multi-class discount may be taken if payments are made on-time (by the 1st DAY of each month, not the 1st class) The multi-class
discount may not be taken if payment arrives after the 1st day of the month. A $10.00 late fee will also be due if payments are late.)
OFFICE USE ONLY
REGISTRATION FEE PAID BY: CASH OR CHECK #__________ ON / /
If paying in full, please indicate amount and date paid: $______________ on / /
MEDWAY DANCE AUTHORITY
2011 REGISTRATION FORM
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